Enhancing routine immunization efforts for older adults and frail individuals: Good practices during the SARS-CoV-2 pandemic in Italy

Infectious diseases pose a significant burden on the general population, particularly older adults who are more susceptible to severe complications. Immunization plays a crucial role in preventing infections and securing a healthier aging, but actual vaccination rates among older adults and frail individuals (OAFs) remains far from recommended targets. This study aims to collect and share good practices implemented in several Italian local health districts during the SARS-CoV-2 pandemic to ease routine immunization for OAFs. A 28-items questionnaire has been developed to collect information on organization aspect of immunization services and local good practices implemented before and during the SARS-CoV-2 pandemic. Twelve Public Health managers representative of 9 Italian Regions were further interviewed between January and March 2021. Despite literature suggests several effective interventions to increase vaccine demand, improve vaccine access, and enhance healthcare providers' performance, our survey highlighted substantial heterogeneity in their implementation at local level. Seven good local practices have been identified and described: mass vaccination centers; vaccination mobile units; drive-through vaccination; co-administration; tailored pathways; cooperation among providers involved in vaccination; digitization. Our survey pointed out valuable strategies for enhancing routine immunization for OAFs. Providers should combine effective interventions adequate to their specific context and share good practices.

Knowledge and beliefs about vaccination in pregnant women before and during the COVID-19 pandemic

Introduction

Vaccine hesitancy threatens the health of populations and challenges Public Health professionals. Strategies to reduce it aim to improve people's risk perception about vaccine-preventable diseases, fill knowledge gaps about vaccines and increase trust in healthcare providers. During pregnancy, educational interventions can provide a proper knowledge about safety and efficacy of maternal and childhood vaccinations. Fighting hesitancy and clarifying doubts is fundamental during the COVID-19 pandemic, which may have affected people's knowledge and beliefs toward vaccination. This study aimed at assessing if the advent of the pandemic was associated with changes in pregnant women's knowledge and beliefs toward vaccination, and trust in healthcare services.

Methods

A repeated cross-sectional study was conducted through self-reported questionnaires in a Roman teaching hospital, where educational classes about vaccinations are routinely held as part of a birthing preparation course. Data were collected on a sample of pregnant women before and during the pandemic. Free-of-charge flu vaccinations were offered to all course participants and adherence to flu vaccination was assessed.

Results

The proportion of pregnant women reporting that vaccines have mild side effects and that are sufficiently tested increased from 78.6 to 92.0% (p = 0.001) and from 79.4 to 93.2% (p = 0.001), respectively. There was a reduction from 33.0 to 23.3% (p = 0.065) in the proportion of those declaring that healthcare workers (HCWs) give information only on the benefits and not on the risks of vaccines, and a reduction from 27.3 to 12.1% (p = 0.001) in those reporting that vaccines are an imposition and not a free choice of mothers. Trust in National Health Service (NHS) operators slightly decreased. Among participants, the monthly flu vaccination adherence ranged from 50.0% in November to 29.2% January for 2019–20 flu season, and from 56.3% in September to 14.5% in January for 2020–21 flu season, showing a higher vaccination acceptance in the earlier months of 2020-21 flu season.

Conclusions

The pandemic may have positively affected pregnant women's knowledge and opinions about vaccinations and trust in HCWs, despite a possible negative impact on their perceptions about NHS operators. This should inspire Public Health professionals to rethink their role as health communicators.

Health Communication in COVID-19 Era: Experiences from the Italian VaccinarSì Network Websites

In 2013, in a bid to combat Vaccine Hesitancy (VH) and provide information on vaccines by communicating with the general public and the health community (e.g., healthcare workers and public health operators), the Italian Society of Hygiene and Preventive Medicine (S.It.I.) published the national website "VaccinarSì". The project was subsequently extended to ten Italian Regions. This led to the creation of the VaccinarSì Network, whose websites are publicly owned. The aim of this work was to present the framework of the websites of the VaccinarSì Network and to analyse user behaviour in the pre-COVID-19-era (dating from each website's publication until 31 January 2020) and in the COVID-19-era (from 1 February 2020 to 31 January 2021). Some metrics such as the number of visits to the site (sessions, number of users and average session duration), user behaviour (pages viewed, bounce rate and organic search) and the session acquisition path (direct traffic, referrals and social traffic) were searched, extrapolated and processed with Google Analytics. Qualitative and normally distributed quantitative variables were summarised with their absolute (relative) frequencies and means. Statistical differences between the means of the two periods were evaluated through paired t-test. A two-tailed p-value less than 0.05 was considered to be statistically significant. When the total values recorded over the period were compared, an overall increase in metrics was observed-the number of individual users, visits and individual pageviews rose in a statistically significant way. Our study aimed to highlight how combining disciplines such as health education and digital communication via Information and Communication Technologies (ICT) represents the best strategy to support citizens. This approach gives them the tools to become independent and responsible players that are capable of voluntarily and consciously choosing to adhere to vaccination programs. The VaccinarSì Network's goal for the future is to reach an even wider audience. By building each user's critical knowledge, this network enables users to be active components of a wider, more empowered community.

Enhancement of Vaccination Attitude and Flu Vaccination Coverage among Pregnant Women Attending Birthing Preparation Course

Most vaccinations are recommended within the 15th month of life, in order to reduce risks and to protect children from the initial stages of their lives. A vaccination training session was carried out during the birthing preparation course, aimed at increasing the attitude toward vaccination in maternal-child age. A questionnaire on vaccination awareness was administered before and after the training session and on-site flu vaccination was offered to women and their companions. The percentage of participants who consider the preparatory course a useful tool to obtain information about vaccines increases significantly from 30.34% at pre-intervention to 64.56% at post-intervention (p < 0.001). There is a significant increase in the mean number of vaccinations that the participants want their children to get. The number of participants believing that there is no relationship between vaccination and autism rose from 41.05 to 72.97% (p < 0.001). In total, 48 out of 119 (40.34%) pregnant women participating in the course and 39 companions were vaccinated for influenza. Vaccination knowledge and attitude significantly increased after a training session dedicated to vaccination as a part of the pregnant pre-birth course, whose aim can be therefore extended to the management of the health of the child, well beyond the period of pregnancy, according to the life-course approach to health.

The impact of a school-based multicomponent intervention for promoting vaccine uptake in Italian adolescents: a retrospective cohort study

BACKGROUND

In Italy, the National Immunization Prevention Plan recommends for adolescents between ages 11 and 18 several vaccines, however their adherence is below the expected coverage. School-based delivery strategies might represent an alternative to primary care settings. This study aims to evaluate the impact of a school-based intervention aimed to increase the vaccination uptake among Italian secondary class students.

METHODS

One of the four schools in which a school-based multicomponent intervention was previously carried out has been matched with a control school in the same geographical area. Students' coverage for mandatory and recommended vaccinations was assessed before and after an 8 months period using the Local Health Authority Immunization Register.

RESULTS

Seven hundred and fifty-five resident students in the RM Local Health Authority were included: 265 from the intervention school, 490 from the control school. At baseline, the two schools were comparable for grades and sex distribution; the intervention school had significant higher immunization rates for Meningococcal B, but lower ones for the 4th dose of dTap. After eight months, higher percentage of students received the HPV (30.5% vs 13.8% of females; p = 0.003) Meningococcal C (6.0% vs 2.0%; p = 0.005) and Meningococcal B (14.7% vs 0.3%; p <0.001) vaccines in the intervention school compared with control. The pre-post differences between the two schools in the immunization rates were significantly higher in the intervention school for the HPV, Meningococcal C and B vaccines.

CONCLUSIONS

This study demonstrates that a school-based health promotion project was effective in improving the recommended vaccines uptake among adolescents with potential interesting implication for the national target attainment. Considering the importance of informing and educating, innovative school-based health promotion programs could represent an excellent opportunity for the Local Health Authorities to get in touch with a hard-to-reach target. Performance in offering the vaccination in school facilities should be evaluated.

The recent Italian vaccination law and the role of Local Health Authorities: the case of LHA Roma 1

Issue/problem

The increase of vaccine hesitancy is leading to decrease vaccination coverage. In Italy, a new vaccination law was approved in July 2017 to contrast the spread of preventable infections. 10 vaccines became mandatory for children and unaccompanied foreign minors aged 0-16 and provided for free according to the national immunization schedule for each birth cohort. Being vaccinated is now required to attend schools and kindergartens even if a ban for students aged 0-6 or a fine for the other are previewed.

Description of the problem

According to the law, in Lazio Region, a web platform was realized in May 2018 in order to permit schools to update the list of their pupils. Medical doctors from LHAs had to evaluate continuously the updated lists, verifying the vaccination status of each student in order to approve their enrolment at schools or to recall parents providing counseling about vaccination.

Results

From August 2018 to March 2019 schools settled in the area of LHA Roma 1 registered 121.687 pupils (among those 105.720 pupils were also resident in the area of LHA Roma 1). After a preliminary check within data already present in the regional vaccination registry, around 30 healthcare operators, from the 6 healthcare districts of LHA Roma 1, were widely involved in order to evaluate pupils’ vaccination status. The number of evaluations decreases in the same period from 19.634 to 4921, but 4908 out of these 4921 were pupils not found in the regional vaccination registry, probably for errors in the registration of personal data such as the fiscal code. Some students’ families received vaccination counseling.

Lessons

The web platform realization was an innovative way to monitor vaccination status: it facilitates a further collaboration among schools and LHAs in order to guarantee health in community and to increase awareness about vaccinations and their benefits. A great involvement of schools and healthcare operators was observed.

Key messages

Although some problems such as pupils not found in the regional vaccination registry persist, the way of working in a collaborative way addressing community troubles is clearly traced. Technology and information systems help community services in monitoring and improving health outcomes. Their use has to be improved and promoted.

Vaccination of classmates for an immunosuppressed child’s protection in a school in the LHA Roma 1

Issue/problem

One of the duty of a State is to guarantee the protection of the health of all citizens, both safeguarding the sick individual needing care and protecting the healthy individual. An important objective of the vaccination prevention programs is to protect people most at risk of contracting infections because of their health conditions.

Description of the problem

In April 2019 the District 14 of Local Health Autority Roma 1 was asked by a father of an immunosuppressed child (6 years old), worried about infectious diseases, to verify the safeness of his child school attendance (the first class of primary school). First, a list of the class mates was asked to the school, in order to check their vaccination status by interrogating the web based regional vaccination register. Then, the District asked to the school to plan a meeting with classmates’ parents and teachers, in order to inform about the importance of a complete immunization both for the classmates and the immunosuppressed child protection.

Results

Preliminary results show that, among 18 classmates, 77.8% had full vaccination coverage for the second dose measles and fourth dose whooping cough (not mandatory for children aged less than 7 years), 22.2% were immunized for chicken pox. Among the parents attending the meeting, 15 agreed to complete their children vaccination cycle, all the teachers agreed to undergo whooping cough and chicken pox vaccination in order to allow a safe school attendance to the immunosuppressed child. Parents and teachers were given an appointment in a vaccination center for the week following the meeting.

Lessons

It is important to promote a real ’vaccination culture’ starting from the school, in order to develop greater citizenship awareness about the potential of vaccinations and to contrast fake news and ignorance leading to dangerous prejudices.

Key messages

The active collaboration between institutions (sanitary and school) allows, through the integration between different competences, to achieve health objectives to protect the community. Talking to pupils’ parents about infectious diseases and their prevention makes it possible to increase knowledge and therefore awareness of the importance of adult and children health protection.

A vaccination campaign in a Roma community in Rome: an experience of the Local Health Autority Roma1

Issue/problem

About 8,000 Roma and Sinti live in the city of Rome, distributed in 33 settlements. This population is particularly at risk of health problems, due to social marginality and reduced access to health and social services. An important challenge for public health is therefore to guarantee and improve the right to health and the availability of health care. In Italy, a new vaccination law was approved in July 2017 and 10 vaccinations became mandatory for minors attending schools.

Description of the problem

In 2018 the District 14 of the Local Health Authority Rome1 (LHA Rome1) organized a vaccination campaign for the Roma and Sinti community being in its area. The aim of the campaign was to analyse the vaccination status of children under-18 living in the camp, based on the local police census data, crossed with the web based regional vaccination registry, to offer free vaccination for those without a regular status, in order to allow school attendance.

Results

Among 109 children living in the targeted Roma and Sinti camp, only 6 (5.5%) had a regular vaccination status according to the Italian law. Two different vaccination opportunity were offered to the community during 2018: a dedicated vaccination session in the local vaccination center, during which 6 children were vaccinated; four vaccination days offered directly at the Roma camp (a total of 53 children were vaccinated). At the end of 2018, the new Police census identified 114 minors resident in the camp instead of 109; of these, 48 (42.1%) had reached a regular vaccination status.

Lessons

Addressing hard-to-reach communities in order to improve the access to health and social services is one of the LHA objectives. The intervention performed in the Roma camp was also an opportunity to promote the importance of vaccination and to inform the target community about various LHA services, in particular maternal and infant services, including those for Temporarily Present Foreigners.

Key messages

The interventions performed straight into communities living in unfavorable health and social conditions are useful to improve the access to health and social services. Vaccination of people living in a social marginality is an important challenge for public health in order to guarantee specific protection measures and promoting the right to health.

[Vaccination among healthcare workers in Italy: a narrative review]

Vaccination of healthcare workers (HCWs) is a public health tool of the utmost importance and the Italian National Vaccine Prevention Plan (PNPV) 2017-2019 recommends several vaccinations in this population group. Nevertheless, vaccine hesitancy is influencing HCWs' attitude towards vaccination. Moreover, a large number of measles cases have been reported in Italy among HCWs in 2017 and 2018. In Italy there is no national registry for vaccinations, so data on vaccine coverage among HCWs are not readily accessible. The aim of this literature review is to describe the most recent data about vaccination coverage among HCWs in Italy. We also report studies that evaluated the effectiveness of strategies to increase influenza vaccine uptake. We included all studies conducted in Italy and published between 2008 and 2018, regarding vaccines recommended by the PNPV 2017-2019 (hepatitis B, influenza, pertussis, measles, mumps, rubella, varicella, and tuberculosis). Our findings confirm that low vaccination coverage levels among HCWs exist in several Italian regions and cities, highlighting a relevant gap towards targets set by the PNPV. Studies that evaluated the effectiveness of multicomponent interventions to increase vaccination coverage found only minimal to moderate increases in uptake levels. It is therefore crucial to tackle vaccine hesitancy in HCWs, by identifying effective strategies able to significantly increase vaccine coverage, in order to decrease the risk of nosocomial infections, prevent transmission of preventable diseases to patients, and reduce indirect costs related to HCW absenteeism due to illness.

Active surveillance for safety monitoring of seasonal influenza vaccines in Italy, 2015/2016 season

BACKGROUND

Surveillance for adverse events following immunization is an important component of any national immunization programme because it is critical to assessing the safety of vaccines and to detecting potentially rare and severe adverse events and responding in a timely manner. We conducted an enhanced active surveillance aimed at assessing the safety of flu vaccines in the 2015-2016 season in Italy. The study was targeted to the population groups for which the seasonal vaccine is recommended in Italy.

METHODS

During the study period, a total of 3213 individuals receiving seasonal influenza vaccination were registered on the web-based platform. Any adverse events experienced after 7 days from vaccination by individuals aged six months or more were collected through a telephone interview or by a web-based self-administered questionnaire. All individuals experiencing at least one event during the 7 days of follow-up were contacted for follow-up to 60 days.

RESULTS

Overall, 854 events were reported: 845 events (26%) after administration of the first dose and 9 (12%) after the second dose. The majority of adverse events reported after 7 days from the first dose were of little clinical importance, and most involved local symptoms.

CONCLUSION

Our data, even though the number of vaccinated individuals was smaller than expected, is consistent with the safety of influenza vaccines in Italy during the 2015-2016 season regarding the most common adverse events. Further efforts are needed to obtain sufficient power to study rarer adverse events. Active monitoring and systematic studies to test generated signals and hypotheses are crucial to intensify awareness among the public and professionals with regard to the safety of vaccines.

[Unhealthy dietary habits among toddlers in Rome (Italy): a cross sectional study]

OBJECTIVE

To explore the nutrition and food habits of toddlers, in order to develop interventions to promote healthy eating starting from the early years of life.

METHODS

We conducted a cross-sectional study among 204 children aged from 3 months to 3 years, registered in 10 nursery schools in Rome, Italy. Children's diet-related behaviors and parent's food attitudes were evaluated using a 10-item questionnaire for parents. After administering the questionnaire, pediatricians of the local health authority conducted motivational interviews with parents to encourage them to make their children adopt healthy behaviors at home. Descriptive and analytical statistical methods were used to evaluate dietary habits in children, after stratifying by nursery school grade attended.

RESULTS

The data showed that unhealthy dietary habits occur even in nursery schoolaged children. In particular, over 50% of children were reported to watch TV while eating meals at home every day and to drink fruit juices at least 1-2 times per week. Unhealthy dietary habits were found to be more common among older children: there were significant differences in the proportions of older and younger children who consumed fruit juices or snacks more than twice per week (35.7% and 8.9% respectively of older children vs 3.3% and 3.3% respectively of younger children), who watched TV during meals (26.8% of older children versus 16.9% of younger children) and whose parents attribute a moral value to food as a reward more than twice a week (almost 14.3% of older children's parents vs 0.0% of small children's parents). On the contrary, older children were found to eat fruit significantly more frequently compared to younger children (51.8% vs 24.6% of young children ate fruit &gt;2 times a week). Parents of children with at least one unhealthy behavior had low awareness of healthy dietary choices: 86.7% believed that their children's diets were healthy.

CONCLUSION

This study showed that unhealthy dietary habits occur among Italian toddlers. These should be prevented by promoting specific interventions. Parents should be made aware of the possible consequences of their own behavior, considering that home food habits influence the development of dietary attitudes in children. Preventive interventions aimed at preschoolers may also be beneficial for parents themselves and for other family members.

The usefulness of sLORETA in evaluating the effect of high-dose ARA-C on brain connectivity in patients with acute myeloid leukemia: an exploratory study

Cytosine arabinoside (Ara-C) is one of the key drugs for treating acute myeloid leukemia (AML). High intravenous doses may produce a number of central nervous system (CNS) toxicities and contribute to modifications in brain functional connectivity. sLORETA is a software used for localizing brain electrical activity and functional connectivity. The aim of this study was to apply sLORETA in the evaluation of possible effects of Ara-C on brain connectivity in patients with AML without CNS involvement. We studied eight patients with AML; four were administered standard doses of Ara-C while the other four received high doses. sLORETA was computed from computerized EEG data before treatment and after six months of treatment. Three regions of interest, corresponding to specific combinations of Brodmann areas, were defined. In the patients receiving high-dose Ara-C, a statistically significant reduction in functional connectivity was observed in the fronto-parietal network, which literature data suggest is involved in attentional processes. Our data highlight the possibility of using novel techniques to study potential CNS toxicity of cancer therapy.

[Audit as a tool to improve the efficiency of the immunization services: the experience of a Local Health Authority in Rome]

INTRODUCTION

The Italian Ministry of Health has launched an alert about the reduction in vaccine coverage (VC), which decreased below 95% since 2014 for many paediatric vaccines, oppositely from the National Prevention Plan 2014-18 and the National Immunization Plan 2017-2019. Even though the growing vaccine hesitancy attracts the attention of the media in the last few years, the organization of an easily accessible and efficient supply network remains a crucial imperative for ensuring satisfactory and uniform vaccine coverage. Taking into consideration some critical issues identified within the vaccination centres of the Local Health Authority (ASL) RM/A, the local health management decided to improve the VC in deep collaboration with all the health professionals. The amelioration process includes the following actions: verifying the current situation, analysing the main concerns, evaluating the possible solution, and activating those already deemed feasible. This paper aims to describe in details the methodology used in the audit and to present the results and actions undertaken following this amelioration process.

METHODS

In the ASL RM/A, which counts 550.000 inhabitants, all the 5 vaccination centres started from 2014 to carry out at least one 30-hour audit each year in order to improve VC. The audits are structured according to the four steps defined by the Ministry of Health to address systematically the critical points identified, by implementing the improvement actions proposed by the audit team to the health management. The audits, accredited under the ECM for the medical and nursing personnel, started in February 2014 and the last edition of the program was completed in December 2016.

RESULTS

During 20 meetings the audit "Centri Vaccinali" involved 11 professionals from 5 vaccine centres, who acknowledged being highly satisfied with the audit, which has been recognized as a valuable tool for improving their work. Following the activities performed in the VC improvement programme, throughout the 3-years period an in-depth review of the most relevant procedures implemented daily by the involved experts was conducted. Moreover, the share of goals and deadlines among the various professionals has leaded to a positive and fruitful collaboration of all experts working in the vaccination centres. This was achieved without creating an additional burden deriving from the improvement process activities. The analysis conducted after two years from the start of the programme has shown not just a significant improvement in vaccine coverage, but also an important increase in the number of vaccine sessions and in the total number of administered vaccines.

CONCLUSIONS

Throughout the described process of improvement, the collaboration among health care professionals was significantly improved and immunization strategies were identified and shared among the centres. The audit demonstrated to be an effective methodology for facilitating the accessibility and usage of vaccination centres by the citizen/user as well as by the healthcare providers. It showed a quick and significant improvement that, by promoting accountability and transparency, will ensure greater efficacy and safety of vaccine services.

The effectiveness of measles-mumps-rubella (MMR) vaccination in the prevention of pediatric hospitalizations for targeted and untargeted infections: A retrospective cohort study

OBJECTIVES

To evaluate the effectiveness of the measles-mumps-rubella (MMR) vaccine in reducing hospitalizations for infectious disease, targeted and not targeted, as well as from respiratory diseases in children in Rome.

METHODS

The cohort was recomposed through record linkage of 2 archives (vaccination register and hospital discharge records.

RESULTS

The analysis included 11,004 children. 20.9% did not receive the MMR vaccination, 49% and 30.1% received one and 2 doses. There were no hospitalizations for rubella, 2 for mumps, and 12 for measles. The vaccine was highly protective against measles and mumps hospitalizations (HR = 0.10; 95% CI: 0.03.0.34). Regarding all infectious diseases there were 414 hospitalizations, and the vaccine was protective (HR = 0.29; 95% CI: 0.25 to 0.34). Concerning respiratory diseases, there were 809 admissions (7.4%), and the vaccine was highly protective (HR: 0.18; 95% CI: 0.07 to 0.48).

CONCLUSIONS

MMR vaccination is effective for the primary prevention of target and not targeted infectious diseases and may also limit hospitalizations for respiratory diseases.

[HPV vaccination: active offer in an Italian region]

Human Papillomavirus is responsible for 4.8% of cancers, and is the main cause of cervical cancer. Cervical cancer can be reduced by mean of secondary prevention (PAP-test, HPV-DNA test), while through primary prevention (anti-HPV vaccine) the incidence of other HPV-attributable cancers can also be reduced. In Italy, anti-HPV vaccination is part of the immunization schedule in girls since 2008, and in 2017 it was extended to boys. However, vaccine coverage is decreasing nationwide. This study aims to examine anti-HPV vaccination practices in Health care services of Lazio Region, Italy. Questionnaires were sent or administered directly to those in charge of vaccinations. Data, collected from 11/12 (92%) Lazio Local Health Units and from 116 vaccination centers, show a remarkable diversity in the offer: 41% of the centers open only 1-2 days/week, 42% only in the morning, and only 7% are open on Saturday. Vaccination is available by reservation only in 62% of the centers, while vaccines are not administered to ≥18 years subjects in 33%; 93% of the centers call actively the girls in the target cohort, while 70% and 94% recall the patients who had not received the first or the second dose of vaccine, respectively. Collaboration with family physicians and/or pediatricians was declared by 80% of the centers. Vaccine coverage could probably be improved by addressing the highlighted critical issues and applying best practices widely.

Knowledge, attitudes and behaviors of the Italian population towards Neisseria meningitidis, Streptococcus pneumoniae and HPV diseases and vaccinations: A cross-sectional multicentre study

OBJECTIVES

This study addressed knowledge of Streptococcus pneumoniae, Neisseria meningitidis and human papillomavirus (HPV), and attitudes and behaviours towards vaccines against them.

STUDY DESIGN

This is a cross-sectional, multicentre study.

METHODS

Data were collected through a questionnaire administered to 530 adults who accessed four Departments of Prevention of the Italian National Health Service in 2013.

RESULTS

Less than 50% of people gave the right answer to all the questions concerning the three diseases, but 96.2%, 94% and 92.7% agreed with the importance of vaccination against N. meningitidis, S. pneumoniae and HPV, respectively, and 58.4% expressed own willingness to have their children vaccinated with N. meningitidis B vaccine. The attitude towards vaccination was more positive in women for N. meningitidis and in people having children for HPV. Furthermore, individuals giving correct answers to all knowledge items were more in favour of both HPV and S. pneumoniae vaccination. A total of 68.8%, 82.6% and 84.5% of respondents vaccinated their own children against N. meningitidis C, S. pneumoniae and HPV, respectively. About 50% of the respondents reported paediatricians' or other health professionals' recommendations as the main reason for vaccination.

CONCLUSIONS

Vaccinations may be promoted through actions aimed at increasing citizens' knowledge. Health professionals should be educated to actively provide information on vaccinations in a clear, comprehensive and effective way.

Evaluation of risk of symptomatic cytomegalovirus reactivation in myeloma patients treated with tandem autologous stem cell transplantation and novel agents: a single-institution study

The introduction of proteasome inhibitors and/or immunomodulators in the treatment of myeloma has led to an increase in viral infections, particularly in the Herpesviridae family. Previous studies about the risk of cytomegalovirus (CMV) reactivation after autologous stem cell transplantation (ASCT) have examined the clinical outcome after the first ASCT; however, only 1 study to date has investigated the risk of CMV reactivation after a second transplantation. To address this issue, we performed a retrospective chart review on 78 consecutive myeloma patients (median age 56 years) who underwent a tandem non-CD34(+) selected ASCT after induction treatment with either conventional chemotherapy (n = 42) or with novel agents (n = 36), respectively. All subjects had been mobilized and conditioned with cyclophosphamide plus granulocyte colony-stimulating factor and melphalan alone, respectively. CMV DNA load in the blood has been determined by polymerase chain reaction in the case of a clinical suspicion of CMV reactivation; therefore, routine monitoring was not performed. Considering the outcome of both the first and the second transplantations, we observed a total of 13 episodes of symptomatic CMV reactivation (13/156, 8%), in 12 subjects (12/78, 15%), all successfully treated. Eight subjects experienced a CMV reactivation after the first ASCT (8/78, 10%); however, only 1 of them (1/8, 12%) experienced a CMV reactivation after the second transplantation. Conversely, 4 CMV reactivations (6%) were observed after the second transplantation in the group of 70 patients who did not experience a CMV reactivation after the first ASCT. No statistically significant difference was observed between first and second ASCT (8/78, 10% vs. 5/78, 6%; P = 0.767). Univariate analysis showed that a pre-transplant treatment with novel agents was the only baseline factor significantly associated with the occurrence of post-ASCT CMV symptomatic reactivation after the first transplant (odds ratio [OR]: 9.897; 95% confidence interval [CI]: 1.154-84.840; P = 0.021) but not after the second transplant (OR: 5.125; 95% CI: 0.546-48.119; P = 0.115). No end-organ disease or primary infection was documented. Our data suggest that second transplantation does not increase the risk of CMV reactivation in our patient population, when compared with the first one, and confirm the role of a pre-transplant treatment with novel agents as a risk factor for CMV symptomatic reactivation.

Action against vaccine-preventable infectious diseases and tuberculosis in Nomad Camps: the experience of a Local Health Unit in Rome

In Italy the highest incidence of Tuberculosis (TB) cases is in young adult migrants. In 2011, the sanitarystaff of the Local Health Unit (ASL) Roma A promoted a vaccination campaign conducting several public health interventions in Nomad Camps. After notification of a case of TB in the Camp of Via Salaria, out of 357 Mantoux skin tests performed, 93 were positive (26%); subsequently, 5 subjects with radiographic positivity were hospitalized. The vaccination campaign was carried out to prevent the spread of infectious diseases in immigrant communities at high risk of contagion and to avoid the consequent transmission in the host country. As a result, vaccinations coverage among the residents of the Camps increased: 367 vaccinated subjects (30% more than previous year) and 612 administered vaccinations.

Is the adjuvanted influenza vaccine more effective than the trivalent inactivated vaccine in the elderly population? Results of a case-control study

INTRODUCTION

Influenza illness is an important public health problem and annual vaccination is globally recommended for high risk populations.

OBJECTIVE

The aim was to evaluate and compare the effectiveness of influenza vaccines in reducing hospitalizations for influenza or pneumonia during two influenza seasons in the elderly.

METHODS

A case-control study was performed, using administrative database of the Local Health Unit Roma-A (LHU RM-A). The included subjects were at least 65 years old and residing in one of the four districts of the LHU. The cases were hospitalized for influenza or pneumonia during influenza season in the years 2010-2011 and 2011-2012. The controls were hospitalized in the same period, but not for influenza or pneumonia. The subjects were immunized with the trivalent inactivated influenza vaccine (TIV) in the first influenza season (2010-2011) and with the adjuvanted influenza vaccine MF59 (ATIV) in the second season (2011-2012).

RESULTS

A total of 269 cases and 1247 controls were included for the 2010-2011 influenza season, and 365 cases and 1227 controls were selected for the 2011-2012 season. Up to 63.6% cases and 53.5% controls in the 2010-2011 season and 78.6% of cases and 64.1% of controls in the 2011-2012 season have not been vaccinated. Female gender and high educational level were protective factors for hospitalization. Subjects over 75 years were at high risk of hospitalization compared to 65-74 years olds. Influenza vaccination reduced significantly hospitalization in both seasons. In subjects with 65-74 years TIV was more effective than ATIV; vice versa for those over 75 years old.

DISCUSSION AND CONCLUSION

TIV and ATIV reduce hospitalization for influenza or pneumonia with a variable degree of protection in different age groups. In particular, ATIV is more effective in individuals over 75 years old.

[Effectiveness of a training course on influenza vaccination in changing medical students' and healthcare workers' attitudes towards vaccination]

A questionnaire study was performed to evaluate the effectiveness of a continuing medical education course on influenza vaccination, held in October 2011, in changing physicians', medical students' and other health care workers' attitudes towards receiving vaccination for seasonal influenza. The questionnaire contained questions regarding influenza, influenza vaccination, and attitudes towards vaccination. Results show that course participants were more likely to get vaccinated against seasonal influenza in 2011 (i.e. following the course) with respect to 2010 and that all professional categories, except students, were positively influenced by the course.

[Vaccination against measles, mumps and rubella in a Roma people camp in Rome, Italy]

The immunization strategy aimed to the elimination of Measles and the prevention of Congenital Rubella failed to reach the planned objectives in Europe; in Italy the renewed National Elimination Plan (PNEMoRc 2010-2015) has been recently approved. The evaluation of a preventive intervention to avoid the spread of measles in a Roma people camp confirm the importance of specific vaccination in high risk populations, like nomads, in which low coverage rates are responsible for the maintenance of the disease.

NK/T-cell lymphomas ‘nasal type’: an Italian multicentric retrospective survey

OBJECTIVE

To evaluate the clinical characteristics and outcome of NK/T-cell lymphoma 'nasal type' developed in Italian patients.

PATIENTS

Between 1997 and 2004, 26 new cases of NK/T-cell lymphoma 'nasal type' were diagnosed in 10 Italian Hematology institutions.

RESULTS

All patients were Caucasian, male/female ratio was 19/7, with a median age of 50 years (range 20-80). In 23 cases presentation at the onset was in the nasal cavity or adjacent structures, in two cases the lymphoma onset with skin lesions was followed successively by rhynopharyngeal dissemination, while the remaining case had bone marrow and lymph node involvement followed by oro-pharyngeal involvement. Regarding the stage of disease: 12 patients were in stage I; six in stage II; eight in stage IV. Diagnosis was based on the finding of a NK/T-cell phenotype at the histological and immunophenotypic examination of oropharyngeal or cutaneous lesions. All patients but one were treated with chemotherapy, alone in nine cases or associated to radiotherapy in 14 cases; two patients had chemotherapy, radiotherapy and surgery, while one patient underwent only surgery. Chemotherapy was anthracycline-based in 17 out of 25 cases. In those patients in whom radiotherapy was performed, radiation dosages ranged between 36 Gy and 47.5 Gy, with a median dosage of 40 Gy. Nine patients (34%) were responsive to the treatments: six patients obtained a complete remission and other three a partial remission. The remaining 17 patients resulted refractory or presented a limited response to therapy. The median disease-free survival was 14 months and the median overall survival time was 9 months.

CONCLUSION

The results of this retrospective survey confirmed that NK/T-cell lymphoma 'nasal type' is a very rare lymphoma in the Italian population, and it is characterized by a very bad prognosis. Due to the rarity of this disease, a standardized therapeutic approach is lacking. More data are needed to know the epidemiology of this kind of lymphoma in Europe.

High-dose hydroxyurea in the treatment of poor-risk myeloid leukemias

The aim of the study was to evaluate the antileukemic effectiveness and toxicity of high-dose hydroxyurea (HHY) and to assess its acute toxicity. Between August 1997 and October 1998, 12 consecutive adult patients (>18 years) with high-risk acute myeloid leukemia (AML) (four patients in first early relapse, seven patients with secondary AML, and one patient with de novo AML concomitant to a lymphoproliferative disorder) were enrolled to receive a single course of HY (100 mg/kg per day) until bone marrow aplasia or for a maximum of 30 days. Of the 12 patients, 5 (41.6%) achieved complete remission (CR), 1 achieved partial remission (PR), 4 were resistant to treatment, and 2 died during induction from infection. No patient with relapsed AML achieved CR, while it was achieved by five of eight patients with secondary AML at diagnosis; five of six MDR1+ patients achieved CR. As concerns follow-up of the CR patients, one did not receive any further treatment and died in CR from pulmonary aspergillosis, and one with a concomitant chronic lymphocytic leukemia (CLL) received two courses of FLAG (fludarabine, cytarabine, granulocyte colony-stimulating factor) regimen with disappearance of the clonal Ig rearrangement, but relapsed after 11 months and died from pneumonia. The remaining three patients were consolidated with two courses of high-dose cytosine arabinoside (AraC), followed by peripheral blood stem cell transplantation (PBSCT) in one patient. One of them relapsed after 3 months, while the other two are still in continuous complete remission (CCR) after 16 and 28 months, respectively. This study has demonstrated the safety and efficacy of HHY in inducing CR in AML patients with unfavorable prognosis. Despite the small number of patients, these encouraging results warrant further studies.

Infectious complications in patients with acute promyelocytic leukaemia treated with the AIDA regimen

Infections represent a frequent complication of chemotherapy used for acute myeloid leukaemia (AML) and are associated with important toxicity frequently leading to treatment discontinuation. Acute promyelocytic leukaemia (APL) is a unique AML subset requiring tailored therapy including all-trans retinoic acid and anthracycline-based chemotherapy. We analysed in this study the incidence and type of infections complicating the clinical course of 89 consecutive APL patients receiving the AIDA protocol at a single institution. A total of 179 febrile episodes were registered during induction and consolidation, 52% of which were of unknown origin. Infections were clinically and microbiologically documented in 10.6 and 37.4% of cases, respectively. Coagulase-negative staphylococci represented the major cause of septicaemia (28%) and were more frequently isolated during induction, whereas viridans group streptococci, the second pathogen most frequently isolated from blood (27%), represented the principal pathogen detected during consolidation and were significantly associated with mucositis. Gram-negative bacteria accounted for 33.3% of all blood isolates. Fungal infections were only occasionally observed. Bloodstream infections in APL patients were compared with those documented in 271 consecutive patients affected by other subtypes of AML. The incidence of total septicaemia episodes, of staphylococcal bacteraemias and of fungaemias was significantly higher in patients with other AMLs. Empirical antibiotic therapy with ceftriaxone plus amikacin was effective in 73% of APL cases, most of the remaining cases being successfully managed by the addition of teicoplanin. One single death apparently related to infectious complication was recorded. Overall, infections led to antileukaemic treatment withdrawal in six patients, five of whom currently remain in haematologic remission for 13-106 months. These results indicate that a particular pattern of infections is observed in APL patients receiving ATRA plus anthracycline-based chemotherapy and that these appear to be effectively counteracted by standard management.

Melphalan treatment in patients with myelofibrosis with myeloid metaplasia

Between January 1985 and December 1992, 104 consecutive patients with symptomatic myelofibrosis with myeloid metaplasia (MMM) [splenic enlargement >5 cm and/or transfusional requirement or Hb < 10 g/dl and/or white blood cell (WBC) count >20 x 10(9)/l and/or platelets >1.0 x 10(9)/l] received low-dose Melphalan (2.5 mg/3 times/week) to evaluate the efficacy and toxicity of this approach. Among 99 evaluable patients, 66 (66.7%) achieved a response after a median time of 6.7 months: 26 (26.3%) had a normalization of all clinical and haematological parameters (complete response, CR) and 40 (40.4%) showed an improvement >50% (partial response, PR). Thirty-three patients (33.3%) were resistant. Reversible haematological toxicity was the most common complication. Median durations of CR and PR were 28.4 and 26 months respectively: median survival of CR + PR patients was 71.2 months (95%CI: 33.8-108.7) versus 36.5 months (95%CI: 24.5-48.5) for the non-responders (log-rank test, P =0.002). In the multivariate analysis, the following variables were significantly associated with a shorter survival: anaemia [hazard risk (HR) = 2.7], WBC count >20 x 10(9)/l (HR = 2.4) and not achieving any type of response, either partial or complete (HR = 3.9). In conclusion, Melphalan could be a promising first-line option for MMM patients with clinical or haematological symptoms requiring treatment.

Spontaneous remission in adult patients with de novo myelodysplastic syndrome: a possible event

BACKGROUND AND OBJECTIVES

Spontaneous remission (SR) in de novo myelodysplastic syndromes (MDS) is a rare event, which has been so far described only in children with monosomy 7. The phenomenon is extremely heterogeneous, perhaps depending on different pathogeneses of the disease.

DESIGN AND METHODS

We retrospectively evaluated the outcome of 564 consecutive adult patients with primary MDS diagnosed at our Institution in a 12-year period. SR was defined as an unexpected improvement lasting more than 1 year without concomitant treatments other than vitamins or low-dose steroids (in patients with platelets < 50 x 10(9)/L).

RESULTS

Nine cases of SR were observed in 3 males and 6 females (median age 38.7 years). At diagnosis, all patients had Hb levels < 10 g/dL and 8/9 required packed red cell transfusions. The median time from diagnosis to SR was 18 months (range 4-46) and all patients had normalization of peripheral blood parameters: in 2 out of 3 patients with karyotypic abnormalities at onset, a cytogenetic remission was documented. The median duration of SR was 56 months; 5 patients are still in SR and 4 patients have relapsed (1 as MDS and 3 as acute myeloid leukemia).

INTERPRETATION AND CONCLUSIONS

SR is a rare (less than 2% in our experience) but possible event also in adult MDS patients. It should be kept in mind in the evaluation of experimental treatments for MDS in which very low rates of complete responses are expected.

Molecular remission following high-dose hydroxyurea and fludarabine plus cytarabine in a patient with simultaneous acute myeloid leukemia and low-grade lymphoma

The occurrence of acute myeloid leukemia (AML) as a secondary tumor has been frequently reported in patients who received various chemotherapy regimens for hematologic malignancies wile the concomitant development of chronic lymphoproliferative diseases (CLD) and AML in previously untreated patients is extremely rare. We report a case with an apparently spontaneous occurrence of AML and non Hodgkin low-grade lymphoma diagnosed by immunological, cytogenetical and molecular analyses. In particular genetic studies allowed to identify the coexistence of a clonal lymphoid population and a myeloid blast component characterized by inv(16) marker and CBFbeta-MYH11 gene fusion. Complete remission of AML and the CLD was obtained following high doses of hydroxyurea and two consolidation cycles of fludarabine plus intermediate dose cytarabine.

Feasibility of peripheral blood stem cell rescue as intensification in elderly patients with acute myelocytic leukaemia: a pilot study from the Gimema Group. Gruppo Italiano Malattie Ematologiche Maligne Dell'Adulto

Elderly patients with untreated acute myeloid leukaemia (AML, n = 47) tested the feasibility of out-patient consolidation therapy and post-consolidation treatment (for patients aged < 71 years) with autologous peripheral blood stem cell transplantation (APBSCT). Overall, 13 patients out of 24 (51%) who achieved complete remission (CR) were eligible for further treatment after consolidation. Five patients were primed with granulocyte colony stimulating factor (G-CSF); a suitable number of CD34+ cells were harvested in three patients and were actually autotransplanted. The toxicity of APBSCT was negligible. Psychosocial problems impaired treatment of some patients on an out-patient basis. Resistant disease, toxicity and logistic problems reduced the number of patients to whom this procedure could actually be applied.

Molecular and cytogenetic remission in a case of subtype M4E acute myelogenous leukemia with minimal monochemotherapy: high sensitivity or spontaneous remission?

Complete remission was observed in an adult patient with acute myelogenous leukemia after minimal monochemotherapy. Remission occurred after a severe febrile pneumonia and was accompanied by cytogenetic and molecular remission. The hypothesis of spontaneous remission was raised, even if a high sensitivity to low-dose cytostatics cannot be excluded. Such spontaneous complete remissions, often associated with bacterial infections and blood transfusions, are extremely rare, and are usually of short duration. Previous cases are summarized, and the role of etiologic factors is discussed.

Acute myeloblastic leukemia secondary to myelodysplasia (MDS-AML): a comparison of remission induction with three drugs versus standard two-drugs induction

To evaluate the addition of a third drug to standard induction chemotherapy in patients with MDS-AML, 23 patients (males/females 13/10, median age 54.3 years, range 24-74 years, median MDS duration 9.8 months, range 2-39 months) who received a standard 2-drugs induction were compared with 23 patients (males/females 11/12, median age 45.6 months, range 21-60 years, median MDS duration 8.3 months, range 2-29 months) who received an intensified 3-drugs induction with etoposide. CR rate, median CR duration and median OS were similar in both groups (48% vs 56%, 4.8 vs 5.9 months, 6.5 vs 7.0 months respectively). Among responding patients, all but one, who underwent allogeneic bone marrow transplantation, relapsed. In conclusion, addition of a third drug (etoposide) does not seem to significantly improve the poor prognosis of MDS-AML patients.

Out-patient management of acute myeloid leukemia after consolidation chemotherapy. Role of a hematologic emergency unit

BACKGROUND AND OBJECTIVE

Increasing attention to quality of life and to health care costs has recently induced several cancer centers to change in-patient management into an out-patient setting even during high risk phases of disease. The aim of this prospective study was to evaluate feasibility and safety, as well as clinical characteristics, of out-hospital management of AML patients during their post-consolidation phase.

DESIGN AND METHODS

All patients who were treated over a three year period by the three following protocols were included in the study: AML10 EORTC/GIMEMA for patients with AML, except for APL, aged </= 60 years; AML 13 EORTC/GIMEMA, for patients with AML, except for APL, aged >60 years; AIDA GIMEMA for APL patients. All patients submitted to the AML10 and AML13 protocols and those patients submitted to the AIDA protocol with difficult peripheral vein access had a central venous catheter (CVC) sited. Patients treated as in-patients were discharged at the end of consolidation chemotherapy provided they were in a good clinical condition. They were routinely evaluated on an out-patient basis twice weekly. In the event of any complication they were referred to the Emergency Unit of our Department dedicated to out-patients with hematologic diseases.

RESULTS

One hundred and eleven patients with AML were eligible for intensive chemotherapy. After achievement of complete remission they received a total of 133 consolidation courses and in 127 instances they were followed on an out-patient basis during the aplastic phase. There were 69 cases (54%) of rehospitalization, 68 because of fever and only one because of severe anemia. Rehospitalization occurred in 90%,70% and 38% of courses in AML10, AML13 and AIDA protocols, respectively. Only one patient died: the cause of death was a brain hemorrhage. Coagulase negative staphylococci and viridans streptococci were the organisms most frequently isolated from blood. Most coagulase negative staphylococci were isolated in patients submitted to AML10 and AML13 protocols, who had an indwelling CVC. Empiric once-a-day antibacterial therapy with ceftriaxone and amikacin was effective in 75% of the cases and made early discharge possible in 28% of the cases with antibiotic therapy continued in an out-patient setting. Overall, patients were managed out of the hospital for 66% of the period of post-consolidation neutropenia (77%, 48% and 50% of the post-consolidation neutropenia period in patients treated with AIDA, AML10 and AML13 protocols, respectively).

INTERPRETATION AND CONCLUSIONS

Thanks to the availability of an emergency unit specifically dedicated to out-patients with hematologic diseases, selected out-hospital management of AML patients during post-consolidation cytopenia is a feasible, well accepted and cost-saving option, and can contribute to lower the risk of developing severe nosocomial infections. The empiric therapy with once-a-day ceftriaxone plus amikacin was effective, with the exception of staphylococcal infections, and made it possible to discharge patients early to continue treatment in an out-patient setting.

Outpatient management of acute promyelocytic leukemia after consolidation chemotherapy

The feasibility and safety of outpatient management of acute promyelocytic leukemia (APL) during the aplastic phase after intensive consolidation chemotherapy, the incidence and types of complications requiring readmission to hospital, and the number of hospital days spared by this policy have been prospectively evaluated. After chemotherapy administration, patients were evaluated on an ambulatory basis. In the event of any complication they referred to the Emergency Unit (EU) of our Department dedicated to outpatients with hematologic diseases. Forty patients with APL observed over a 4 year period were eligible for intensive chemotherapy. After the achievement of complete remission they received a total of 104 consolidation courses and in 98 instances they were followed on an ambulatory basis. There were 41 cases (42%) of rehospitalization for fever (40 cases) or severe anemia (one case). Only one patient died due to a brain hemorrhage. Streptococcus viridans was the organism most frequently isolated from blood. Empiric once-a-day antibacterial therapy with ceftriaxone and amikacin was effective in 87% of the cases and made possible early discharge in 28% of the cases to continue the antibiotic therapy on an outpatient setting. Patients were managed out of the hospital for 76% of the post-consolidation neutropenia period. Thanks to the availability of an EU specifically dedicated to outpatients with hematologic diseases, out-hospital management of APL patients after consolidation therapy appeared to be safe, well accepted, potentially cost-saving, and contributed to saving the risk of developing severe nosocomial infections.

Polycythemia vera treated with pipobroman as single agent: low incidence of secondary leukemia in a cohort of patients observed during 20 years (1971-1991)

The 'gold standard' for the treatment of polycythemia vera (PV) is to date undefined. We performed a retrospective analysis to evaluate the outcome of a cohort of PV patients treated with pipobroman (PB) at a single institution during a period of 20 years (November 1971-October 1991). During this period, a total of 366 adult PV patients were diagnosed according to Polycythemia Vera Study Group (PVSG) criteria. Of these, only 199 (54%) were treated with PB: 92 were males and 107 females, median age was 63.0 years (range 25.2-87.3 years). Major clinical characteristics at onset were as follows: 34 (17%) patients had splenomegaly >3 cm below costal margin, 70 (35%) had platelets >600,000/mm3, 79 (40%) had white blood cells >12,000 mm3; 97 (49%) had hypertension, 83 (42%) had minor neurological symptoms (as vertigo, headache, paresthesias), 33 (17%) had pruritus and 27 (13%) had thrombotic features. All patients received PB at the dosage of 1 mg/kg/day until response was achieved (hematocrit value <50% in males and <45% in females). Thereafter treatment was given according to toxicity and maintenance of response. All patients were phlebotomized before starting treatment (mean number of phlebotomies performed: three, range 2-4) and 47 of them received PB when hematocrit value was already reduced at response levels: therefore, while all patients are evaluable for acute and long-term toxicity, only 152/199 (76.4%) patients are evaluable for response to PB. During a median time of 2 months, all these 152 patients achieved the response; as maintenance, 128/199 (64.3%) patients were managed with PB alone and 71/199 (35.7%) patients received phlebotomies occasionally. Sixty-one out of 199 (30.6%) patients developed disease-related complications (25 neurological symptoms, 21 thrombotic complications, 12 cardiovascular problems, three hepatic failures). Eleven (5.5%) patients developed acute myelogenous leukemia (AML) after a median time of treatment of 89 months (range 33-188 months), 11 (5.5%) patients developed myelofibrosis (median time from treatment 71 months, range 31-182 months) and in six (3%) patients cancer occurred (median time from treatment 85 months, range 13-118 months). The cumulative risk of leukemia in PV was 2% (95% CI: 0-4%) and 6% (95% CI: 1-11%) at 5 and 10 years respectively; the cumulative risk of myelofibrosis was 2% (95% CI: 1-5%) and 9% (95% CI: 3-15%) at 5 and 10 years, respectively. As of May 1996, 33 (16.6%) patients are lost to follow-up, 40 (20.1%) are dead and 126 (63.3%) are alive with a median overall survival of 191 months. In conclusion, this retrospective analysis confirms the efficacy and safety of PB in PV patients and its low leukemogenic role; prospective studies are needed to evaluate the real impact of PB in the treatment of PV.

The role of all-trans-retinoic acid (ATRA) treatment in newly-diagnosed acute promyelocytic leukemia patients aged > 60 years

BACKGROUND

To evaluate the role and toxicity of ATRA therapy in newly-diagnosed APL patients aged > 60 yrs, the outcome of 16 consecutive elderly APL patients observed between January 1990 and June 1996 were analyzed.

PATIENTS AND METHODS

Their median age was 65.5 yrs (range 60-81 years), the male/female ratio was 7:9, and molecular biology analysis showed a PML/RARa rearrangement in all patients. Seven patients had a concomitant cardiovascular disease. ATRA 45 mg/sqm/day was given to all patients, and in 11 was associated with idarubicin (AIDA protocol); in two patients ATRA was associated with mitoxantrone + ara-C, while the remaining three patients received ATRA alone.

RESULTS

Fourteen patients (87.5%) achieved CR, and two patients (12.5%) died during induction. Despite the high CR rate, eight episodes of severe cardiovascular complication were observed in seven patients, three of whom had previously had cardiovascular disease; in addition, three patients had sepsis (two bacterial and one fungal). As of 31 March 1997, 9 of 14 patients were still in first CR after a 19-month (range 7-64 months) median follow-up since attainment of the CR. One patient died in CR of a fungal complication and four patients relapsed after 8, 9, 23 and 35 months following CR: two of them achieved a second CR lasting seven and +15 months with ATRA alone. Of the nine patients still in first CR, only three have received the planned consolidation therapy and five have been in CR for more than 24 months (+25, +33, +34, +38, +63).

CONCLUSIONS

Despite the fact that most of these patients received shorter consolidation treatments than do younger patients, the good results achieved in them might be considered an indication for modifying treatment schedules in order to reduce severe toxicity and improve protocol compliance.

Salvage lung resection for massive hemoptysis after resolution of pulmonary aspergillosis in a patient with acute leukemia

A 58-year-old woman with acute myelogenous leukemia in complete remission underwent successful pulmonary resection for massive hemoptysis occurring after resolution of pulmonary aspergillosis. Despite the fact that the role of surgery in the treatment of pulmonary mycosis in immunocompromised hosts is still to be clearly defined, emergency lung resections can be successfully performed in this group of patients with almost immediate recovery of stable clinical parameters. Brisk recovery can reduce overall morbidity and mortality and allow for early resumption of any necessary treatment for underlying disease.

Treatment of high-risk myelodysplastic syndromes with lymphoblastoid alpha interferon

Seventeen patients with high-risk myelodysplastic syndromes (HR-MDS) received lymphoblastoid-interferon alpha (Ly-IFN alpha) for 3 months at escalating doses from 0.5 to 3 MU s.c. 3 times per week. Three patients stopped the treatment after 2 months because of cardiac failure (one patient) and cerebral haemorrhage (two patients); six had a partial response (PR) and continued Ly-IFN alpha; six were resistant and stopped Ly-IFN alpha; two evolved to acute myelogenous leukaemia (AML). Among the six partial responders, four achieved a complete response (CR) during subsequent Ly-IFN alpha treatment (CR duration 3, 4+, 15+ and 29 months) and two did not achieve any further improvement (PR duration 3 and 9 months). Two resistant patients had an unexpected clinical improvement soon after Ly-IFN alpha discontinuation and achieved a PR of 6+ and 14+ months respectively. No toxicity related to Ly-IFN alpha treatment was observed and no reduction of dosage was needed.

IN CONCLUSION

(1) Ly-IFN alpha seems to be effective in some patients with HR-MDS; (2) the best treatment duration seems to be of a least 6 months.

MEC (mitoxantrone, etoposide and intermediate dose cytarabine): an effective induction regimen for previously untreated acute non-lymphocytic leukemia

Twenty-three patients with acute non lymphocytic leukemia (ANLL), were treated with a single-6 day course of Mitoxantrone 6mg/m2/day, Etoposide 80mg/m2/day and intermediate dose Cytarabine (ara-C) 1g/m2/day (MEC). Patients who achieved complete remission (CR) were submitted to a 4-day-course of MEC as consolidation. Seventeen patients (73.9%) obtained CR, five patients (22.7%) were resistant to the treatment and one patient died during induction. Median remission duration was 11 months; overall median survival was 16 months. Relapses occurred in 11 patients; eight patients are still alive: 6 in 1st, 2 in 2nd CR (mean survival 20.1 months, range 17-26). All patients experienced severe myelosuppression comparable to that observed after classical induction cycles including ara-C in continuous intravenous infusion; none, however, died of infection. Non-hematologic toxicity was minimal; in particular, neurotoxicity was not observed. According to our results, the MEC regimen, which was previously demonstrated to be active in refractory patients, represents an effective induction treatment in ANLL, with an acceptable toxicity.

The retinoblastoma gene product in acute myeloid leukemia: a possible involvement in promyelocytic leukemia

The retinoblastoma susceptibility gene in leukemia and lymphoma has been investigated using different approaches involving either gene or protein analysis. In this study, a novel method, which evaluates the functional status of the retinoblastoma gene product by a binding assay to an in vitro-translated viral oncoprotein, has been applied to leukemic cells from acute myeloid leukemia patients. One hundred twenty-two cases were considered, and 42 of them were also analyzed by Western blot. Results obtained with the two methods were comparable, with the exception of few cases, where the retinoblastoma protein appeared detectable but unable to bind to the viral oncoprotein. The retinoblastoma protein has been found defective mostly in the M3 promyelocytic subtype.

Is aggressive chemotherapy the best choice for patients with acute nonlymphocytic leukemia after myelodysplastic syndromes?

Myelodysplastic syndromes (MDS) evolve in overt acute nonlymphocytic leukemia (ANLL) in about 40% of patients: the treatment of ANLL-MDS is not yet well clarified. To identify the role for aggressive and conservative approaches in ANLL-MDS, we evaluated retrospectively 78 patients in a 7-year period. Thirty-one patients (16 males and 15 females, median age 57.5 years, median MDS duration 5.5 months) were eligible for aggressive chemotherapy; 17 patients (54.8%) achieved complete remission (CR), 10 (32.3%) were resistant and 4 (12.9%) died during induction from infective complications. All patients that achieved CR relapsed, with a median CR duration of 6 months (range 2-28 months); median survival of the whole group was 8.5 months, while median survival of responders was 9 months. No prognostic factor revealed a statistical significance in the outcome, due to the small number of patients in each subgroup. Forty-seven patients (27 male and 20 female, median age 71.8 years, median MDS duration 10.1 months) were not eligible for aggressive chemotherapy; 16 patients (34.2%) received supportive care only, 31 patients (65.8%) needed conservative chemotherapy for disease progression. Median survival of the conservatively treated group was 5.5 months, without statistical difference from the aggressively treated group; 10/47 conservatively treated patients (21%) survived for longer than 12 months. In conclusion, aggressive chemotherapy may play a role only in a selected population of ANLL-MDS patients, while further studies could be helpful to identify the optimal conservative approach.